This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley. Alarm Signals Our body’s alarm system alerts us to danger or potential danger. This alarm system is composed of sensors throughout the body, the eyes, nose, and ears. It is these sensors that are our first line of defense against harm. If one sensor fails the others take over. Most of these sensors are located in the brain and respond to various stimuli. Some to mechanical movement, some to temperature change; the sensors in the brain particularly respond to chemical activity. What is important to know with sensors is that they have a very short life expectancy of a few days. This cycling means our body’s sensitivity is constantly changing. It is with these life cycles that there is hope for those with chronic pain. Moreover, the rate at which sensors are made is normally stable but can change very quickly in regards to a particular stimulus. So if we take for example one with persistent pain, the rate at which pain sensitivity occurs can be changed. Nociception We lack pain receptors in our bodies. Instead, the various tissues have special neurons that respond to different stimuli. These receptors are called nociceptors, which translates into “danger receptors.” Nociception is occurring all the time, but only sometimes will it end in pain. Nociception is neither necessary nor sufficient for pain. The sensors correspond to particular neurons. In order for these neurons to become excited and
Read MoreThe Sensitive Nervous System Chapter XV: Clinical Aspects of Neurodynamics
This is a summary of chapter XV of “The Sensitive Nervous System” by David Butler. Intro In this chapter we discuss many specific neurodynamic pathologies and implementing the nervous system into treatment approach. Conservative Nervous System Decompression Here is a general step-by-step approach to decreasing threat throughout the nervous system. 1) Decrease tissue sensitivity by removing relevant stimuli and decreasing CNS threshold. 2) Improve container tissue health. 3) Improve the nerve tract’s ability to absorb traction forces. 4) Assess and improve the nerve to container relationship. 5) Assess/modify any adverse ergonomic or environmental factors. Carpal Tunnel Syndrome Tests to perform. ULNT1 & reverse. ULNT2 (median) & reverse. Compression (can add ULNT). Phalens and reverse Phalens. Phalens + ULNT. Treatment There are several options to treat carpal tunnel syndrome. Mobilizing not only the median nerve, but radial and ulnar is beneficial because the nerves are closely connected. Movement is critical because nerve inflammation and swelling does not leave the carpal tunnel easily. This problem is because there are minimal lymphatic channels in the tunnel. Nerve Root Complex Nerve root issues often have corresponding postural adaptations. Cervical – forward head posture. Lumbar – Flat lumbar spine with knees flexed, positioned toward the injured sign. In acute instance, it may be okay to let the patient rest in these antalgic postures until AIGS settle. Other presentations indicative of nerve root complex pathology include numbness/tingling down the extremities. Other possibilities include coldness, shooting, tiredness. Pain rarely goes into the extremities. Double Crush Double crush
Read MoreThe Sensitive Nervous System Chapter XIV: Management Strategies: Integration of Neurodynamics
This is a summary of chapter XIV of “The Sensitive Nervous System” by David Butler. The Big Picture Evidence Based Approach Here is the step by step patient care process that Butler advocates. 1) Identify red flags and manage accordingly. 2) Educate on the whole problem to include tissue health status, the nervous system’s role, and test results. 3) Provide prognosis and make realistic goals. 4) Promote self-care, control, and motivation. 5) Decrease unnecessary fear and manage catastrophization. 6) Get patients moving as early as possible. 7) Help patients identify success and sense of mastery of a problem. 8) Perform a skilled exam. 9) Acknowledge that biopsychosocial inputs combine with the nervous system to produce pain and disability. 10) Use any measures possible to reduce pain. 11) Minimize number of treatments and contacts with all medical personnel. 12) Chronic pain may need a multidisciplinary approach. 13) Manage physical function and dysfunction. 14) Assess and assist in improving general fitness. 15) Assess how injury affects creative outlets and assist the patient with regaining creativity and discovering new creative outlets. Incorporating Neurodynamics There are several ways to incorporate neurodynamics into the patient’s plan of care which will be outlined below. Reassessment. Explanation. Passive mobilization. Active mobilization. Posture and ergonomics. Reassessment There are many evaluation protocols that warrant constant reassessment after applying an intervention. Be it a comparable sign or audit, neurodynamic tests can be utilized well within these systems. A word of caution with instant reassessment, as quick changes could merely be
Read MoreThe Sensitive Nervous System Chapter XIII: Research and Neurodynamics: Is Neurodynamics Worthy of Scientific Merit?
This is a summary of Chapter XIII of “The Sensitive Nervous System” by David Butler. Intro Research has demonstrated that often evidenced-based medicine is low on the list for why clinicians choose a particular treatment. From an ethical standpoint, it is important to consider evidence. This chapter is very short so I will just provide the highlights that I got from it. Appraising a New Theory or Approach There are six criteria that a new theory should be evaluated by: 1) Support from anatomical and physiological evidence. 2) Designed for a specific population. 3) Studies from peer-reviewed journals. 4) Include a well-designed randomized controlled trial or single experiment. 5) Present potential side effects. 6) Proponents discuss and are open to limitations. Agreement Here are some definitions of different ways research measures agreement. – Cohen’s Kappa: Measures nominal data reliability. >0.75 is excellent agreement. 0.40-0.75 is fair to good. <0.40 is poor. – Pearson product movement correlation: Measures interval/ratio data. – ICC: Measures continuous data. The closer to 1, the better. Validity There are also many different validity types defined throughout this chapter. The first two are proven through logic and have the least evidence support. – Construct Validity: Valid relative to a theoretical foundation. – Content Validity: Can I use this measure to make an inference? The next two are higher up on the evidence support hierarchy. – Convergent Validity: The test shows a correlation between two variables. – Discriminant Validity: The test shows a low correlation between two variables.
Read MoreThe Sensitive Nervous System Chapter XII: Upper Limb Neurodynamic Tests
This is a summary of Chapter XII of “The Sensitive Nervous System” by David Butler. Intro Today we will take a look at assessing upper limb neurodynamic tests (ULNT). These assessments used to be called tension tests, but that terminology is now a defunct mechanical description. We now describe these as neurodynamic tests to better appreciate the neurophysiologic aspects of mechanosensitivity and upper limb homunculi stability. These tests are numbered based on the movement sensitizer, which are as follows: 1 – Shoulder abduction. 2 – Shoulder depression. 3 – Elbow flexion. ULNT1: Median Nerve Here is the quick test first. Here is how to do the manual test. A quick heads up regarding head motions. Sidebending away increases symptoms in 90% of people. Sidebending toward decreases symptoms in 70% of people. ULNT2: Median Nerve Here is the manual test ULNT2: Radial Nerve Here is the active test. And the manual test. ULNT3: Ulnar Nerve Here is the active test And the manual test. Musculocutaneous Nerve Here is the active test And the passive test. Axillary Nerve Here is the passive test. Suprascapular Nerve Here is the test. Final Words Have some fun with these tests, and be mindful that you are not too aggressive. Thanks to Scott and Sarah for your videotaping help. You guys rock.
Read MoreCourse Notes: Graded Motor Imagery
I recently attended another great course through the NOI Group called “Graded Motor Imagery” (GMI) taught by Bob Johnson. These guys are the industry leaders in all things pain so please check them out. It was great connecting with Bob and learning what I think will be an excellent adjunct to what I am currently doing. So here is the run down on GMI. Overview GMI is a three-pronged sequential process of establishing early, nonpainful motor programming. Johnson calls this synaptic exercise to limit negative peripheral pain expression. GMI is a 3 step process: 1) Laterality reconstruction (Implicit Motor Imagery). 2) Motor imagery (Explicit Motor Imagery). 3) Mirror Therapy. The Neuromatrix Paradigm & Pain States Before delving into the neuromatrix, we first must define pain. Pain is a multiple system output or expression by an individual-specific pain neuromatrix that activates when the brain concludes that body tissues are in danger and action is required. The neuromatrix, like I talk about in this post here, is the nervous system’s coding space and network. It is first and foremost affected by genetics, sculpted by experience, and constantly evolving. It is the entity that makes us who we are—the self. The neurosignature, or neurotag, is an output’s representation in the brain. For example, regions in the brain will activate in response to produce the pain output. This sequence is the neurosignature. Some common activated areas when pain is expressed include both primary and secondary somatosensory cortices, insula cortex, anterior cingulgate cortex, thalamus, basal
Read MoreThe Sensitive Nervous System Chapter XI: Neurodynamic Testing for the Spine and Lower Limb
This is a summary of Chapter XI of “The Sensitive Nervous System” by David Butler. Intro For today’s chapter, I have decided that the best way to learn these tests is to show you. I will write in any pertinent details you need for a good test performance. The Straight Leg Raise (SLR) SLR hacks. Add sensitizers (dorsiflexion, plantarflexion, etc) to determine nervous system involvement. Add cervical flexion or visual input to enhance responses. Be mindful of symptoms before and after pain responses. If this test is positive post-operation, it will likely be inflammatory in nature. You can preload the system further with cervical flexion or sidebending the trunk away from the test side. Here are some other ways to perform the SLR with sensitizers first. (I apologize for the way the camera shot in advance). For tibial nerve-bias. For fibular nerve bias. For sural nerve bias. Passive Neck Flexion (PNF) Here is how to perform the test. PNF Hacks. Add SLR to further bias the test. Be mindful of Lhermitte’s sign, which is an electric shock down the arms or spine. This is a must-refer sign as there is potential spinal cord damage. Slump Test Here is how to perform the slump. Slump Knee Bend In the book itself, Butler uses the prone knee bend as his base test. However, NOI does not teach this motion as much and now favors the slump knee bend. This movement allows for much more differentiation to be had. And the saphenous nerve
Read MoreThe Sensitive Nervous System Chapter X: Neurodynamic Tests in the Clinic
This is a summary of Chapter X of “The Sensitive Nervous System” by David Butler. The Tests When assessing neurodynamics, there is a general system that is used including the following tests: Passive neck flexion (PNF). Straight leg raise (SLR). Prone knee bend (PKB). Slump. 4 different upper limb neurodynamic tests (ULNT). I will demonstrate these tests for you in later chapters. Many clinicians when discussing the lower extremity-biased tests deem that maybe only one or two of the tests need to be performed, however this assertion is erroneous. Slump, SLR, and PNF all need to be tested as a cluster. The reason being is that the clinical responses may often differ. This difference is especially noticeable when comparing the SLR and the slump. These two are not equal tests for the following reasons: Components are performed in a different order. Spine position is different. Patients may be more familiar with the SLR, therefore give more familiar responses. The patient is in control during the slump, not in the SLR. The slump is more provocative. Rules of Thumb When testing neurodynamics, here are the following guidelines: 1) Active before passive. 2) Differentiate structures – add/subtract other movements to see if symptoms can change. 3) Document the test order. Positive Test The positive testing here is a little dated based on what Butler’s group and the research says as of right now. Based on what I have learned from Adriaan Louw, having any of the following is what constitutes a positive
Read MoreThe Sensitive Nervous System Chapter IX: Manual Assessment of Nerve Conduction
This is a summary of Chapter IX of “The Sensitive Nervous System” by David Butler. The Value The neurological exam is an excellent way to sample the patient’s nervous system. When looking at the neurological system, we must realize that testing does not reflect a tissue injury alone. It demonstrates the neurological pathway’s response. There is no such thing as a focal lesion in the nervous system. We must also understand that the exam is a very small component of a further comprehensive assessment, providing moderate diagnostic value at best. Sensitivity for a screen like this is inherently poor, meaning this examination cannot rule out nervous system pathology or involvement. Sensory Examination If we are going to walk the neurological walk, we first need to talk the neurological talk. Here are some important definitions. Allodynia: Pain from a non-painful stimulus. Hyperalgesia: Increased response to a painful stimulus. Analgesia: No pain from a painful stimulus. Hyperpathia: Abnormal pain reaction to a repetitive stimulus. Hypoalgesia: Decreased response to a painful stimulus. Hypoesthesia: Decreased sensitivity to a stimulus. Hyperesthesia: Increased sensitivity to a stimulus. Dysesthesia: Unpleasant, but not painful response to a stimulus. First, we will take a look at dermatomes. Now depending on who you talk to, dermatomal levels will be different. Moreover, many people have anatomically variant dermatomes, and often times these can fluctuate throughout the day. There are however, some signature zones that are fairly consistent throughout the literature. There are several different sensations that need to be tested. Make
Read MoreThe Sensitive Nervous System Chapter VIII: Palpation and Orientation of Peripheral Nervous System
This is a summary of Chapter VIII of “The Sensitive Nervous System” by David Butler. Intro Palpation is a major component to therapeutic touch, and gives us a way to build rapport and interact with our patients. When palpating the nervous system, it is important to palpate in sensitive positions so the nervous system is placed on load. Here are some general nerve anatomical rules. Where a nerve has fewer fascicles and less connective tissue, palpation will be more sensitive (ulnar nerve). Where there is a lot of connective tissue, there will be a more localized and less “nervy” response. Where there is increased sensitivity does not mean there is damage locally. Damage could have occurred more proximally (that whole nerves fire in both directions thing). You must also be mindful that anatomical variations are common, especially if symptoms seem anatomically weird. Here are some of the more common ones: Martin-Gruber anastomosis: Median and ulnar communicate distally. Rieche-Cannieu anastomosis: Deep branch of ulnar and recurrent branch of median nerve. Absent musculocutaneous nerve. Palpation 101 Here are some basic nervous system palpation guidelines. Nerves feel hard and slippery. Palpate with your finger tip or thumb, and follow it proximally or distally. Use sustained pressure up to 30 seconds. Twang if easily accessible. If using a Tinel’s, tap the nerve 4-6 times. Spinal Nerve Palpation Here are the craniocervical nerves. The Trunk Upper Extremity Nerve Palpation Brachial plexus The median nerve The Ulnar nerve The Radial Nerve The Musculocutaneous Nerve Lower Extremity
Read MoreExplain Pain Section 1: Intro to Pain
This is a summary of the first section of the book “Explain Pain” by David Butler and Lorimer Moseley. Intro The major premise of this book is that pain is normal. It is the way that your brain judges a situation as threatening. Even if there are problems in the body, pain will not occur if your brain thinks you are not in danger. Explaining pain can reduce the threat value and improve pain management. And the good thing about explaining pain? Research shows that it can be an easily understood concept. Pain is Normal Pain from bites, postures, sprains, and other everyday activities are more often than not changes in the tissues that the brain perceives as threatening. This system is very handy, as often it keeps us from making the same mistake twice. I personally akin this to patients as recognizing a certain smell and that smell reminding you of something. Pain is often the reminder of previous injuries. Pain becomes problematic when it becomes chronic. This pain is often the result of the brain concluding that for some reason, often a subconscious one, that the person is threatened and in danger. The trick is finding out why. Pain Stories Stories are some of the best ways to relate pain to patients. There are many cases when you hear soldiers sustaining major injuries yet charging further into battle. On the flipside, take a look at paper cuts. The damage is very miniscule; however, the pain levels are huge.
Read MoreCourse Notes: The Eclectic Approach to Upper Quarter Evaluation and Treatment
I recently attended this course with my man Erson Religioso III. It was great connecting with him and learning his approach. Check out his stuff on www.themanualtherapist.com Overall, I thought it was an excellent course and definitely opened my mind to an approach (i.e. McKenzie) that I was not a huge fan of. I highly recommend taking one of his courses. Here were some of the pearls I got from his course. My thoughts will be italicized. On Assessments “If you don’t have a system, you are lost in an evaluation.” The SFMA reasons why people get hurt. #1 cause – previous injury. Asymmetry of quality and quantity. Motor control. Stupidity. Just because you clear something once doesn’t mean it has been cleared forever. If one has knee pain and decreased ankle dorsiflexion, check tibial internal rotation. On Education “Never tell people they are train wrecks.” This goes back to reducing the threat response and explaining pain. We want to maximize the placebo effect. On Neuroscience Nerves move like an arm in a sleeve. A tight sleeve wears down myelin which is replaced with ion channels. This is why nerves become sensitive. Also why you must treat the entire nerve container. Abnormal impulse generating site (AIGS) These fire both ways. Not normally at the sight of symptoms. If symptoms are episodic, then it is not centrally maintained. If you skin your knee 10 times in 10 years, you don’t say I have a chronic skinned-knee problem. On Surgery “Less than
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